Coroner's report on Waihola Lake death

WATER DEPTH ANALYSIS NEEDED: Pure Insanity being retrieved after it flipped on Lake Waihola.

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Tearful relatives of Invercargill woman Lyn Burnett are critical about the level of ambulance coverage at a boating event after a coroner yesterday found she received subobtimal care.

Ms Burnett was filling in as a crew member on Garry Sexton's racing boat Pure Insanity at the annual Milton Boat Club Marathon at Lake Waihola on July 2 last year when it flipped.

In an interim finding at an inquest in Dunedin yesterday, Otago Southland coroner David Crerar said Ms Burnett died in Dunedin Hospital on July 6 as a result of chest and lung injuries leading to a brain injury from a lack of oxygen and shock.

Mr Crerar said suboptimal medical care was one of a cascade of components that contributed to her death; the other was the boat crash itself.

Ms Burnett's brother, David Burnett, and eldest son, Brayden Kyle, expressed frustration that race organisers failed to ensure there was an advanced or intensive-care ambulance crew at the scene.

There had been two volunteer ambulance officers at the event but one was also competing.

"It's a bit out there if you ask me," a tearful Mr Kyle said in response to the failures identified at the hearing.

"I'm just saying next time I'd love it if you just had two guys on the ground."

David Burnett reacted to concessions by organiser representatives Hugh Howat and Ian Spencer that they would do better next time, as they gave evidence at the hearing.

"There shouldn't be a next time," he said. "It surprises me a bit that this race was run with the medical backup they had."

Mr Burnett said he was involved with the sport of BMX, which paid for ambulances to attend events no matter how isolated the location.

Other motor sports did the same, and boating should be no different, he said.

He rejected evidence by Mr Howat that the boat race was constrained as to emergency medical personnel it had available because its rural ambulance service was mainly volunteer.

"It's no excuse to say you live in Milton or Waihola. It's unsatisfactory. There should have been an ambulance on site."

Mr Howat said he had tried to obtain ambulance cover but could not get it.

Mr Spencer acknowledged points made by the relatives, saying organisers were shocked by the death.

"I know it's a bit late but we have addressed the issue."

Dunedin Intensive Care Ambulance officer Patrick Bain told the inquest Ms Burnett might have been saved if he had been at the scene.

He could have immediately administrated a procedure to relax the patient enough to get a tube down into the lungs so air could be administered.

Mr Bain believed he would have also recognised the need to call for a rescue helicopter.

Ms Burnett was handed over to Mr Bain by a Milton St John Ambulance part way to Dunedin on the day of the boat crash.

Mr Bain said he had been told Ms Burnett's issue was pain relief.

He said intubation was unsuccessful by the time he began treating Ms Burnett because she had lockjaw, making it almost impossible to pass a tube through her mouth.

Mr Crerar said he had received an undertaking from St John Ambulance that it would re-view its level of intubation training, currently in the pilot stages, as a result of Ms Burnett's death.

It now recognised there was a lack of sufficiently trained personnel nationwide who could carry out intubation.

Maritime investigator Bruce McLaren, who carried out a technical investigation into the crash for Police, said the boat had no mechanical faults that could have contributed to the crash.

Police told the hearing there were no suspicious circumstances into Ms Burnett's death.

Mr McLaren recommended that in future boat race organisers analyse the depth of water-ways before proceeding with an event.

He believed the accident could have been caused by the boat's motor hitting silt on the lake floor because of the low level of the water, the boat's speed, and where it was sitting on the water during the race.